assisting individuals in crisis

ASSISTING INDIVIDUALS

IN CRISIS

The following guidelines are provided as general

recommendations only and are not intended to be clinical

prescriptions, nor are they intended to be used by those other than

individuals qualified to do so.

Copyright ICISF, 2005

ASSISTING INDIVIDUALS IN CRISIS Topical Outline

Section One - Key Terms & Concepts

Section Two - Are You Listening?

Section Three - Crisis Communication Techniques

Section Four - Questions

Section Five - Psychological Reactions in Crisis

Section Six - Mechanisms of Action

Section Seven - Do No Harm!

Section Eight - The SAFER-Revised Model

ASSISTING INDIVIDUALS IN CRISIS Topical Outline

Revised 10/2005

OBJECTIVES: Participants will…

1. Understand the natures & definitions of a psychological crisis and psychological crisis intervention.

2. Understand key issues and findings of evidence-based, and evidence-informed practice as it relates to psychological crisis intervention.

3. Understand the resistance, resiliency, recovery continuum.


4. Understand the nature and definition of critical incident stress management and its role as a continuum of care.

5. Practice basic crisis communication techniques.

6. Be familiar with common psychological and behavioral crisis reactions, including empirically-derived predictors of posttraumatic stress disorder.

7. Understand the putative and empirically-derived mechanisms of action in psychological crisis intervention.

8. Practice the SAFER-Revised model of individual psychological crisis intervention.

9. Understand how the SAFER-Revised model may be altered for suicide intervention.

10. Understand and discuss the risks of iatrogenic “harm” associated with psychological crisis intervention and will further discuss how to reduce those risks.


SECTION ONE

KEY TERMS

&

CONCEPTS

THE NEED

Over 80% Americans will be exposed to a

traumatic event (Breslau) About 9% of those

exposed develop PTSD (40-70% IN RAPE,

TORTURE) (Surgeon General, 1999)

Disasters may create significant impairment in

40-50% of those exposed (Norris, 2001,

SAMHSA)

THE NEED

About 50% of disaster workers likely to

develop significant distress (Myers & Wee,

2005)

Terrorism likely to adversely impact majority

of population (IOM, 2003); Ranges from

~ 40 - 90% (JHU, 2005)

Dose response relationship with exposure

PTSD Prevalence: 10 - 15% of Law

Enforcement Personnel (see Everly &

Mitchell, 1999)

PTSD Prevalence: 10 - 30% of those in Fire

Suppression (see Everly & Mitchell, 1999)

PTSD Prevalence: 16% Vietnam Veterans

(Nat PTSD Study)

THE NEED

PTSD Prevalence: ~ 12% Iraq War Veterans

(NEJM, 2004)

As many as 45% of those directly exposed to

mass disasters may develop PTSD or

depression (North, et al., 1999, JAMA)

THE NEED

At the heart of any field of study or practice

resides a basic vocabulary. The following

definitions will set the stage for the

material we will cover in this course.

DEFINITIONS

CRITICAL INCIDENTS are

unusually challenging events that

have the potential to create

significant human DISTRESS and

can overwhelm one’s usual coping

mechanisms.

THE ICEBERG EFFECT OF

TERRORISM (and disasters)…

more psychological casualties than

physical casualties…80/20 Effect?

(Holloway, et al., 1997, JAMA; DiGiovanni, 1999,

Am. J. Psychiatry)

DEFINITIONS

The psychological DISTRESS in

response to critical incidents such as

emergencies, disasters, traumatic

events, terrorism, or catastrophes is

called a PSYCHOLOGICAL CRISIS

(Everly & Mitchell, 1999)

PSYCHOLOGICAL CRISIS

An acute RESPONSE to a trauma, disaster,

or other critical incident wherein:

1. Psychological homeostasis (balance) is

disrupted (increased stress)

2. One’s usual coping mechanisms have failed

3. There is evidence of significant distress,

impairment, dysfunction

(adapted from Caplan, 1964, Preventive Psychiatry)

DEFINITIONS

CRISIS INTERVENTION

A short-tem helping process.

Acute intervention designed to mitigate the

crisis response.

Not psychotherapy.

CRISIS INTERVENTION Goals: To foster natural resiliency through…

1. Stabilization

2. Symptom reduction

3. Return to adaptive functioning, or

4. Facilitation of access to continued care

(adapted from Caplan, 1964, Preventive Psychiatry)

IMPORTANT!

Crisis intervention targets the

RESPONSE, not the EVENT, per se.

Thus, crisis intervention and disaster

mental health interventions must be

predicated upon assessment of need.

CRITICAL INCIDENT STRESS

MANAGEMENT (CISM) (Everly & Mitchell, 1997, 1999; Everly & Langlieb, 2003)

A comprehensive, phase

sensitive, and integrated,

multi-component approach to

crisis/disaster intervention.

CRISIS INTERVENTION

Historical roots of current crisis

intervention practices can be found

in military psychiatry, community

mental health, and suicide intervention

initiatives.

Military foundations for crisis

intervention have evolved since

1919:

Proximity

Immediacy

Expectancy

And later added:

Brevity

Simplicity

RESEARCH FINDINGS

Not all mental health

professionals agree that

crisis intervention / disaster

psychological intervention

is useful.

Note: The term “debriefing” is

often used as a synonym for crisis

intervention / disaster mental

health / early psychological

intervention.

Concern over perceived indiscriminant use

of psychological crisis intervention has led

to recommendations to wait 1-3 months

post event before initiating formal

psychological intervention using 4-12

sessions of Cognitive Behavioral Therapy

(CBT).

[see Friedman, M., Foa, E., & Charney, D. (2003). Toward evidence-based

early intervention for acutely traumatized adults and children. Biological

Psychiatry, 53, 765-768.]

Concerns have been fueled

by publication of the

Cochrane Reviews…

Major concern over the applicability of

early psychological intervention arose

largely from the Cochrane Reviews (1998,

2002).

Other negative reviews (van Emmerick, et

al., 2002; McNally, et al., 2003) were based

largely upon Cochrane data sets, and

subsequent theoretical speculation as to

potential mechanisms of pathogenic

iatrogenesis.

COCHRANE REVIEW (2002)

“Debriefing” = 11 RCT studies of 1:1

counseling with medical / surgical patients,

“loosely based” upon outdated (1983) model

“Debriefing” = “single session individual

debriefing did not reduce psychological

distress nor prevent PTSD”

COCHRANE REVIEW (2002)

3 studies showed worsening of symptoms

The authors conclude: “We are unable to

comment on the use of group debriefing, nor

the use of debriefing after mass traumas.”

Findings more recent and more

relevant to disaster mental

health tend to support the use

of crisis intervention…

LESSONS LEARNED FROM

CONSULTATION MENTAL HEALTH (Stapleton, Medical Crisis Intervention, 2004)

Early Psychological Intervention is

enhanced via the use of multiple

interventions on PTS (.62 vs .55)

LESSONS LEARNED FROM THE

WORKPLACE

Post disaster crisis intervention (CISM) was associated with reduced risk for

binge drinking (d=.74),

alcohol dependence (.92),

PTSD symptoms (.56),

major depression (.81),

LESSONS LEARNED FROM THE

WORKPLACE

Post disaster crisis intervention (CISM)

was associated with reduced risk for

anxiety disorder (.98), , and

global impairment (.66),

compared with comparable individuals who did

not receive this intervention (Boscarino, et al, IJEMH,

2005).

“There is now emerging evidence that

prompt delivery of brief, acute phase

services in the first weeks after an event can

lead to sustained reduction in morbidity

years later, reducing the burden of

secondary functional impairment, presumed

daily average life years lost (DALYS), and

costs to both the individual and the public”

(p.15).

Schreiber, M. (Summer, 2005). PsySTART rapid mental health triage and incident command system.

The Dialogue: A Quarterly Technical assistance Bulletin on Disaster Behavioral health, 14-15.

Value added of Crisis Intervention: Screening & Increasing Access to Care

First responders, military personnel, and civilian disaster workers (North, et al., 2002, J. T. Stress; Hoge et al. 2004, NEJM; Jayasinghe, et al.,

2005, IJEMH) often resistant to seeking MH treatment, therefore crisis intervention may be their only access to mental health services

Up to 76% of those that go on to develop posttraumatic morbidity may show predictors within 24 hours (North, et al., 1999, JAMA)

EARLY PSYCHOLOGICAL

INTERVENTION SHOULD NOT BE USED

SPECIFICALLY AS A MEANS TO

PREVENT PTSD; RATHER, consider as a

platform for screening, reducing acute distress,

fostering group cohesion, providing info,

anticipatory guidance (Litz, et al., 2002, Clin

Psychol; Everly & Langlieb, 2003, IJEMH; Arendt &

Elklit, 2001, Acta Psyc Scand)

EMPLOYEE ASSISTANCE PROFESSIONAL’S ASSN –

DISASTER RESPONSE TASK FORCE (EAPA, 2002)

EAPs should develop workplace disaster plans.

Plans should consist of a continuum of interventions:

Pre-Incident Training / Coordination (early intervention CISM training, resiliency training, risk assessment, policy development)

Acute Response

Post-Incident Response (defusing, CISD, crisis management briefings, assessment/ referral, self-care)

Follow-up (supervisory briefings, assessment, training)

Post-Incident review and plan reformulation

REASONABLE EVIDENCE-BASED

CONCLUSIONS

More, better controlled, research needed

Care must be taken

Data reviewed support use of group “debriefing” with

emergency services personnel (Arendt & Elklit, 2001)

Data reviewed tend to support use of group “debriefing”

subsequent to disasters, war, robbery (see NIMH, 2002,

tables 2-3;)

REASONABLE EVIDENCE-BASED

CONCLUSIONS

Data do not support single session individualized

interventions after medical, surgical distress with minimal

training

Data support multi-component intervention systems

NIMH (2002), Institute of Medicine (2003) recommend

acute phase “psychological first aid” (no direct data

available)

Recent recommendations for early

intervention include the use of a

variety of interventions matched to

the needs of the situation and the

recipient populations

(Mental Health & Mass Violence, 2002; IOM, 2003)

A CONTINUUM OF CARE

The Johns Hopkins’

RESISTANCE, RESILIENCE, RECOVERY

An outcome-driven continuum of care

Create Resistance Enhance Resiliency Speed Recovery Assessment Assessment Assessment

Intervention Intervention Intervention

Evaluation Evaluation Evaluation

[Kaminsky, et al, (2005) RESISTANCE, RESILIENCE, RECOVERY. In Everly & Parker,

Mental Health Aspects of Disaster: Public Health Preparedness and Response. Balto: Johns

Hopkins Center for Public Health Preparedness.

In the present context, the term resistance

refers to the ability of an individual, a group,

an organization, or even an entire

population, to literally resist manifestations

of clinical distress, impairment, or

dysfunction associated with critical

incidents, terrorism, and even mass disasters.

Resistance may be thought of as a

form of psychological / behavioral

immunity to distress and dysfunction.

Resistance may be best built via

pre-incident / pre-deployment

training.

In the present context, the term resilience

refers to the ability of an individual, a

group, an organization, or even an entire

population, to rapidly and effectively

rebound from psychological and / or

behavioral perturbations associated with

critical incidents, terrorism, and even mass

disasters.

It is likely that early psychological

intervention (i.e., response oriented

crisis and disaster mental health

intervention) is best thought of as a

means of enhancing resiliency.

The term recovery refers to the ability of an

individual, a group, an organization, or even an

entire population, to literally recover the ability to

adaptively function, both psychologically and

behaviorally, in the wake of a significant clinical

distress, impairment, or dysfunction subsequent to

critical incidents, terrorism, and even mass

disasters.

Treatment and rehabilitation programs are most

likely the interventions of choice to speed

recovery.

A REVIEW OF INTERVENTION

TOOLS

Categories of Disaster Mental Health

Interventions (adapted from NVOAD- EPI Subcommittee Consensus Points, 2005)

Pre-incident training

Incident assessment and strategic

planning

Risk and crisis communication

Acute psychological assessment and

triage

Crisis intervention with large groups



Crisis intervention with small groups

Crisis intervention with individuals, face-to-face and hotlines

Crisis planning and intervention with communities

Crisis planning and intervention with organizations

Psychological first aid



Facilitating access to appropriate levels of

care when needed

Assisting special and diverse populations

Spiritual assessment and care

Self care and family care including safety

and security

Post incident evaluation and training based

on lessons learned

One approach, that has been

frequently used, to integrate such

an array of crisis / disaster mental

health interventions across a

continuum of need is Critical

Incident Stress Management (CISM; Everly & Mitchell, 1999).

As noted earlier…


MANAGEMENT (CISM) (Everly & Mitchell, 1997, 1999; Everly & Langlieb, 2003)

A comprehensive, phase

sensitive, and integrated,

multi-component approach to

crisis/disaster intervention.

CISM is a strategic intervention

system.

It possesses numerous tactical

interventions.

A Comprehensive, Integrated Multi-Component

Crisis Intervention System (adapted from: Martha Starr)

Each “leaf” represents a specific tactical intervention.

ELEMENTS OF CISM

Pre-incident education, preparation

Assessment

Strategic Planning

Large Group Crisis Intervention:

Demobilizations (large groups of rescue / recovery)

Respite / Rehab Sectors

Crisis Management Briefings (CMB)

ELEMENTS OF CISM

Small Group Crisis Intervention:

Defusings (small groups)

Small group CMB

“Debriefing” Models: Critical Incident Stress Debriefing (CISD); HERD; NOVA; Multi-stressor debriefing model; CED

ELEMENTS OF CISM

One-on-one crisis intervention, including individual PFA

Family CISM

Organizational / Community intervention, consultation

Pastoral crisis intervention

Follow-up and referral for continued care

CORE COMPETENCIES OF

COMPREHENSIVE CRISIS

INTERVENTION

Assessment/ triage benign vs. malignant

symptoms

Strategic planning and utilizing an integrated

multi-component crisis intervention system

within an incident command system

CORE COMPETENCIES OF

COMPREHENSIVE CRISIS

INTERVENTION

One-on-one crisis intervention

Small group crisis intervention

Large group crisis intervention

Follow-up and referral

REVIEW:

“The Evolving Nature of Disaster

Mental Health Services”

APPENDIX A provides a brief

overview of numerous crisis. Disaster

mental health interventions.

THOUGHTS ON

STRATEGIC PLANNING

The challenge in crisis intervention

is not only developing TACTICAL

skills in the “core intervention

competencies,” but is in knowing

WHEN

to best STRATEGICALLY employ

the most appropriate

intervention for the situation.

1. THREAT

2. TARGET (Who should receive services?

ID target groups.)

3. TYPE (What interventions should be used?)

4. TIMING (When should the interventions be

implemented, with what target groups?)

STRATEGIC PLANNING FORMULA

5. RESOURCES (What intervention

resources are available to be mobilized for

what target groups, when? Consider

internal and external resources.)

[Note: THEMES which may modify impact and

response should be considered (children,

chem-bio hazards, etc?)]


PEER SUPPORT:

A Special Kind of Crisis

Intervention

The provision of crisis intervention services by

those other than mental health clinicians and

directed toward individuals of similar key

characteristics as those of the providers,

e.g., emergency services peer support,

student peer support, etc.

Jerome Frank, PhD, MD once

noted that at the core of

psychological healing resides an

“anti-demoralization effect”

SECTION TWO

ARE YOU LISTENING?

GROUP EXERCISE

GROUP EXERCISE

George

Ralph

Dawn

Capt

Tom

HAVING COMPLETED THE

GROUP EXERCISE

What role did “ASSUMPTIONS” play?

What role did VALUES play?

What are the implications for

COUNTERTRANSFERENCE REACTIONS,

especially with regard to PEER

INTERVENTIONISTS?

SECTION THREE

CRISIS COMMUNICATIONS

CRISIS COMMUNICATION

TECHNIQUES

Paracommunications: Silence and

Nonverbal Behavior

“Mirror” Techniques

Questions

Action Directives

BEWARE!

Excessive use of silence in crisis

situations can communicate lack of

interest, thus causing an escalation.

Nonverbal behavior sends a

powerful message.

Often, the first impression you make

is based upon how you look.

The challenge is how to make that

impression useful in the service

of crisis intervention.

“MIRROR TECHNIQUES”

Restatement

Paraphrase (Summary & Extrapolation)

Reflection of Emotion (Commonly

Used By Hostage Negotiators)

“MIRROR” TECHNIQUES

Are effective when placed at a natural pause in the conversation

Or, may be used to redirect the flow of a tangential conversation

Or, can be used break an escalating emotional spiral

RESTATEMENT

Takes the other person’s words and

restates only the term or phrase about

which you wish to inquire or emphasize

Do not overdo this technique

Demonstrates concern, listening

SUMMARY PARAPHRASE

Simply summarizes in your words, the

main points made by the person in crisis

Usually inserted when the person pauses

Stems might include: “So, in other

words…” or “Sounds like…” or “What

I’m hearing you say is…”

EXTRAPOLATION

PARAPHRASE

People in crisis seldom understand

the consequences of their actions

Extrapolation = summary +

consequences

May be a behavior change tool

REFLECTING EMOTION

Based upon verbal or nonverbal cues

Attempts to accurately label the experienced emotion of the other person (“you seem really angry…”)

Builds empathy, rapport

Encourages ventilation

Helps defuse anger

COMMUNICATION

EXERCISE:

INTERVIEW USING

SUMMARY PARAPHRASING

&

REFLECTING EMOTION

(Observer’s Form #1)

SECTION FOUR

QUESTIONS AND THE

“DIAMOND” COMMUNICATION

STRUCTURE

QUESTIONS

CLOSED-END (“do you…?” “Is this…?” “Did

you…?”)

Multiple choice

Open-end (“How?” “What”)

Remember, paraphrases and reflections are

closed-end questions

A simple structure for

asking questions is

called the “diamond”

structure.

“DIAMOND” STRUCTURE

Begin asking closed-ended questions in order

to establish basic facts

Move to open-ended questions in order to

probe and obtain more information

Use paraphrase and reflection of emotion to

summarize key points and acknowledge

emotions

OPEN QUESTIONS

TO PROBE/ EXPAND

CLOSED END QUESTION (“YES-NO”)

TO ESTABLISH FACTS

PARAPHRASE (closed question)

TO SUMMARIZE

ACTION DIRECTIVES

Providing direction on what to do

If someone asks a direct question, it is

usually best to provide a direct answer,

unless the answer will cause an

escalation of the crisis

COMMUNICATION EXERCISE:

EMPHASIZING USE OF

YES-NO QUESTIONS

(Be sure to use open-end questions,

paraphrasing & reflection of

emotion)

(Use Observer’s Form #2)

SECTION FIVE

PSYCHOLOGICAL

REACTIONS IN CRISIS

EUSTRESS vs. DISTRTESS vs. DYSFUNCTION

Three intensity levels of stress:

Eustress = Positive, motivating stress

Distress = Excessive stress

Dysfunction = Impairment

SIGNS AND SYMPTOMS OF

DISTRESS

I. COGNITIVE (Thinking)

II. EMOTIONAL

III. BEHAVIORAL

IV. PHYSICAL

V. SPIRITUAL

DISTRESS (excessive stress).

Rx…Identify, Assess, & Monitor

vs.

DYSFUNCTION (impairment)

Rx…Identify, Assess, & Take

action

I. COGNITIVE (Thinking) DISTRESS

Sensory Distortion

Inability to Concentrate

Difficulty in Decision Making

Guilt

Preoccupation (obsessions) with Event

Confusion (“dumbing down”)

Inability to Understand Consequences of

Behavior

I. SEVERE COGNITIVE DYSFUNCTION

Suicidal/ Homicidal

Ideation

Paranoid Ideation

Persistent Diminished

Problem-solving

Dissociation

Disabling Guilt

Hallucinations

Delusions

Persistent

Hopelessness/

Helplessness

II. EMOTIONAL DISTRESS

Anxiety

Irritability

Anger

Mood Swings

Depression

Fear, Phobia,

Phobic

Avoidance

Posttraumatic

Stress (PTS)

Grief

II. SEVERE EMOTIONAL

DYSFUNCTION

Panic Attacks

Infantile Emotions in Adults

Immobilizing Depression

Posttraumatic Stress Disorder (PTSD)

Posttraumatic stress (PTS) is

a normal survival response;

Posttraumatic Stress Disorder

(PTSD) is a pathologic

variant of that

normal survival reaction.

Predicting PTSD

1. Dose - response relationship

with exposure

2. Personal identification with

event

3. Very important beliefs violated

PTSD results from violation of:

1. EXPECTATIONS

2. DEEPLY HELD BELIEFS

(Worldviews)

CORE BELIEFS (Worldviews)

Belief in a just and fair world

Need to trust others

Self-esteem, Self-efficacy

Need for a predictable and SAFE world

Spirituality, belief in an order and

congruence in life and the universe

III. BEHAVIORAL DISTRESS

Impulsiveness

Risk-taking

Excessive Eating

Alcohol/ Drug Use

Hyperstartle

Compensatory

Sexuality

Sleep Disturbance

Withdrawal

Family Discord

Crying Spells

Hypervigilance

1000-yard Stare

III. SEVERE BEHAVIORAL

DYSFUNCTION

Violence

Antisocial Acts

Abuse of Others

Diminished Personal Hygiene

Immobility

Self-medication

IV. PHYSICAL DISTRESS

Tachycardia or Bradycardia

Headaches

Hyperventilation

Muscle Spasms

Psychogenic Sweating

Fatigue / Exhaustion

Indigestion, Nausea, Vomiting

IV. SEVERE PHYSICAL

DYSFUNCTION

Chest Pain

Persistent Irregular Heartbeats

Recurrent Dizziness

Seizure

Recurrent Headaches

IV. SEVERE PHYSICAL

DYSFUNCTION

Blood in vomit, urine, stool, sputum

Collapse / loss of consciousness

Numbness / paralysis (especially of

arm, leg, face)

Inability to speak / understand

speech

It is imperative that all evidence

of physical dysfunction be taken

seriously and referred to a

physician. The same is true when

dealing with any physical distress

that does not remit, may be

suggestive of a medical disorder,

or seems ambiguous.

V. SPIRITUAL DISTRESS

Anger at God

Withdrawal from Faith-based Community

Crisis of Faith

V. SEVERE SPIRITUAL

DYSFUNCTION

Cessation from Practice of Faith

Religious Hallucinations or

Delusions

NOTE!

ALL OF THE SIGNS AND

SYMPTOMS OF SEVERE

DYSFUNCTION WARRANT

REFERRAL TO THE NEXT

LEVEL OF CARE!

Also refer whenever in doubt.

11 Screening Factors:

1. Ask about nature & severity of exposure

2. Ask about peri-traumatic dissociation

3. Ask if person truly believed he / she was

going to die

4. Ask about appraisal of symptoms (are they

catastrophic?)

5. Physical injuries

11 Screening Factors:

6. Malignant sympathetic arousal – panic,

loss of bowel or bladder control

7. Psychogenic amnesia

8. Peri-traumatic depression, numbing

9. Self-destructive ideation

10. Evidence of psychotic process

11. Whenever in doubt!

FOR EXAMPLE

Have you recently . . .

1. Seen anyone seriously injured or killed?

Or have you seen any type of human

remains?

2. Felt as if you were in serious danger, or

thought that you were going to die?

In the last couple of weeks, or so,

have you…

3. Felt hopeless, helpless, or seriously

depressed?

4. Felt numb or detached from the people

you were with, your surroundings, or even

from your usual bodily sensations?

5. Seriously thought about hurting yourself, or

ending you own life?

6. Seriously thought about hurting or killing

someone else?

7. Thought you were “going crazy?”

8. Experienced panic?

9. Experienced a crisis of spiritual,

or religious, belief?

10. Had difficulty getting along with close

friends, family, or co-workers?

11. Used alcohol, or other substances

specifically to help you relax or sleep?

12. Would you be interested in talking to

someone about any of these, or other,

concerns you might have?

SECTION SIX

MECHANISMS OF ACTION IN

CRISIS INTERVENTION

Remember Maslow’s (1943) Need

Hierarchy

Self – actualization

Self – esteem

Affiliation

Safety

Basic physical needs (START HERE)

PERSONALITY ALIGNMENT

COGNITIVE ORIENTATION

vs.

AFFECTIVE ORIENTATION

PSYCHOLOGICAL

ALIGNMENT

Don’t argue

Don’t minimize problem

Find something to agree upon

Is the most important element in

establishing rapport

MECHANISMS OF ACTION (rec-Recommended; emp - Data based; rev - Review of literature)

MEETING BASIC NEEDS (NIMH, 2002-rec)

LIAISON / ADVOCACY (NIMH, 2002-rec

CATHARTIC VENTILATION (Pennebaker,

1999-emp)

SOCIAL SUPPORT, GROUP COHESION

(Flannery, 1990-emp; APA, 2004-rec)

INFORMATION (NIMH, 2002-rec)

MECHANISMS OF ACTION (rec-Recommended; emp - Data based; rev - Review of literature)

STRESS MANAGEMENT (Everly & Lating,

2002-rev)

PROBLEM-SOLVING (Everly & Lating,

2002-rev)

CONFLICT RESOLUTION (Everly & Lating,

2002-rev)

COGNITIVE REFRAMING (Taylor, 1983-emp;

Affleck & Tennen, 1996-rec)

SPIRITUAL (Everly & Lating, 2002-rev)

AVOID!

“I know how you feel.”

“It’s not so bad.”

“This was God’s will.”

“God won’t give you more than you can handle.”

“Others have it much worse.”

AVOID!

“You need to forget about it.”

“You did the best you could.”

(Unless person has told you that.)

“You really need to experience this pain.”

Psychotherapeutic interpretation!

Confrontation

Paradoxical intention.

EXERCISE

PRACTICE IN CRISIS

INTERVENTION

MECHANISMS


SECTION SEVEN

DO NO HARM:

Cautions & Contraindications

CRISIS = RESPONSE

The failure to understand that the

event is NOT the crisis, can easily

lead to over intervention, and the

potential to interfere with natural

recovery mechanisms!

CAN CRISIS INTERVENTION BE HARMFUL ?

Theoretical Mechanisms/ Issues

(see Dyregrov, IJEMH, 1999; Watson, et al., in Ursano & Norwood, 2003)

Excessive catharsis, disclosure, rumination

Pathologizing otherwise “normal” reactions

Vicarious traumatization in groups

Coercive peer pressure in groups

Scapegoating in groups

CAN CRISIS INTERVENTION BE HARMFUL ?

Theoretical Mechanisms/ Issues

(see Dyregrov, IJEMH, 1999; Watson, et al., in Ursano & Norwood, 2003)

Triggering of previous traumatic memories

Intervention may be premature (inappropriate timing)

May be inappropriate with highly aroused persons

May interfere with natural coping mechanisms

May not be accompanied by adequate assessment or

follow-up

The risk of adverse outcome is associated with all human

intervention and helping practices including medicine,

surgery and counseling.

Improper, inadequate training would appear the greatest

risk factor associated with crisis intervention, as well as

those practices just mentioned.

Thus, training and supervision may be the best way to

reduce the risk of adverse outcome, rather than simply

calling for an end to such helping practices

SECTION EIGHT

SAFER-Revised MODEL OF

INDIVIDUAL CRISIS

INTERVENTION

Crisis Intervention applications can

be made easier by the utilization of

simple models. The SAFER-R

model is nothing more than a

step-by-step model for working with

individuals in crisis

The SAFER-Revised

Stabilize (introduction; meet basic needs; mitigate acute stressors)

Acknowledge the crisis (event, reactions) Consider reflecting emotion, then asking the question

what would be most helpful to the person in crisis.

Facilitate understanding (normalization)

Encourage effective coping (mechanisms of action)

Recovery or Referral (facilitate access to continued care)

SAFER-R Model of Crisis Intervention with Individuals (Everly, 2001)

Stabilization (plus Introduction ) [1]

Acknowledgement [1]

A. Event

B. Reactions

Facilitation of Understanding: Normalization [1]

Encourage Effective Coping (Mechanisms of Action) [1,2,3]

Referral? [1, 2, 3]

[1= Assessment, 2= Generate intervention options, 3= Implement interventions]

SAFER-R Model of Crisis Intervention with Individuals (Everly, 2001)


Acknowledgement [1]

A. Event

B. Reactions


Encourage Effective Coping (Mechanisms of Action) [1,2,3] MEETING BASIC NEEDS

LIAISON/ ADVOCACY

CATHARTIC VENTILATION

SOCIAL SUPPORT

INFORMATION

STRESS MANAGEMENT

PROBLEM-SOLVING

CONFLICT RESOLUTION

COGNITIVE REFRAMING

SPIRITUAL

Referral? [1, 2, 3]

[1= Assessment, 2= Generate intervention options,

3= Implement interventions]

AN EXAMPLE Introduce yourself

Meet basic needs, stabilize, liaison

Listen to the “story” (events, reactions)

Reflect emotion

Paraphrase content

Ask a transitional question: “What do you

need most right now?”

AN EXAMPLE Normalize

Attribute reactions to situation, not personal weakness

Identify personal stress management tools to empower

Identify external support / coping resources

Use problem-solving or cognitive reframing, if applicable

Assess person’s ability to safely function

SUICIDE: A SPECIAL CASE

Helplessness

Hopelessness

Extreme guilt

Previous attempts

Severe illness, disability

Psychosis

SUICIDE: C-C-D-R Intervention

CLARIFY

CONTRADICT

DELAY

REFER for continued to care

SUICIDE INTERVENTION

CLARIFY: “Do you really want to die, or

do you simply want to change the way you

live your life?

CONTRADICT via:

Desired outcome will not be achieved

Suicide will create more problems than it solves

Suicide creates an adverse and undesired

“ripple effect” affecting others

SUICIDE INTERVENTION

DELAY

ALWAYS ASSIST IN ACCESSING

HIGHER LEVEL OF CARE

SAFER-R Model of Crisis Intervention with Individuals:

Modified for Suicide Intervention (Everly, 2001)


Acknowledgement [1]

A. Event

B. Reactions


Encourage Effective Coping (Mechanisms of Action) [1,2,3]

CLARIFY, CONTRADICT, DELAY

Referral…ALWAYS! [1, 2, 3]

[1= Assessment, 2= Generate intervention options,

3= Implement interventions]

EXERCISE

PRACTICE IN SAFER-Revised


Peter Volkmann, MSW, NOAI

47 Stuyvesant Place

Stuyvesant, N.Y. 12173

[email protected]

518-758-2315

mailto:[email protected]

APPENDIX A

Commonly Used Crisis and Disaster

Mental Health Interventions

PRE-INCIDENT PREPARATION

Assessment of risk

Risk reduction

Assessment of physical and psychological

response preparedness

Training to reduce vulnerabilities

Training to create “resistance”

Training to enhance “resilience” and

response capabilities

ASSESSMENT

One element often left out of

crisis intervention is acute

assessment, e.g., mental status,

behavioral assessment, the Johns

Hopkins’ “perspectives,” etc.

ALL Crisis Intervention should be

based upon the Assessment of

NEED…and the further

ASSESSMENT of the most

appropriate intervention.

A strategic planning model may

assist in this process.

1. THREAT

2. TARGET (Who should receive services?

ID target groups.)

3. TYPE (What interventions should be used?)


4. TIMING (When should the interventions be

implemented, with what target groups?)

5. RESOURCES (What intervention resources

are available to be mobilized for what target

groups, when? Consider internal and external

resources.)

[Note: THEMES which may modify impact and response

should be considered (children, chem-bio hazards, etc?)]


DEMOBILIZATION

A one time, large-group information

process for emergency services,

military or other operations staff who

have been exposed to a significant

significant traumatic event such as a

disaster or terrorist event

RESPITE/ REHAB SECTORS

Ongoing physical & psychosocial

decompression (respite) areas constructed

at the disaster venue to provide support

(beverages, light food, protection from

weather, and provision of psychological

support / stress management) typically to

emergency personnel.

CRISIS MANAGEMENT BRIEFINGS (CMB) (Everly, 2000)

Structured large group (can be used in small

groups, as well) community / organizational

“town meetings” designed to provide

information about the incident, control

rumors, educate about symptoms of distress,

inform about basic stress management, and

identify resources available for continued

support, if desired. Especially useful in

response to violence / terrorism.

DEFUSINGS

Small group (< 20) structured

3-phase group discussion regarding a

critical incident.

Typically done with homogeneous

work groups usually within 12 hours

of the event.

May be repeated for ongoing

events.

“DEBRIEFING”

The term “debriefing” has

been used frequently in

the theory and practice

of crisis intervention.

Used within the context of CISM,

the term “debriefing” refers to a

7 - phase structured small group

crisis intervention more

specifically named Critical

Incident Stress Debriefing (CISD).


DEBRIEFING (CISD) (Mitchell & Everly, 2001)

A structured 7-phase group discussion typically

conducted with homogeneous groups 2 - 10 days

(3+ weeks in mass disasters) post incident.

Designed to mitigate distress, facilitate

psychological closure, or facilitate access to

continued care.

In 1983, Mitchell’s original paper used the term

CISD to refer to both the overarching response

system and the small group discussion.

This resulted in semantic confusion.

Now, the term Critical Incident Stress

Management (CISM) is used to denote the

overarching response system, while CISD is

used to refer to the 7-phase small group

discussion.

The term “debriefing,” when used alone, has been used

in so many different ways, it has lost its meaning and adds to confusion.

For example, research from the UK often uses the term debriefing to describe 1:1 counseling with medical patients.

Unfortunately, some reviews and studies have used the term debriefing to describe such forms of counseling. Further, the Cochrane Review has been inappropriately cited as evidence of the ineffectiveness of all forms of “debriefing,” even group CISD!

INDIVIDUAL (1:1) INTERVENTION

Most crisis intervention is done

individually, one-on-one,

either face-to-face or telephonically.

Psychological first aid (PFA) is the

most elemental form of this

intervention.

FAMILY CRISIS INTERVENTION

Traumatic distress can be “contagious;”

family members are often adversely affected

by those who initially develop posttraumatic

distress.

AND

Families of victims require support,

especially when loved ones are seriously

injured or killed.

ORGANIZATIONAL /

COMMUNITY

CRISIS RESPONSE

Consists of risk assessment, pre- and post

incident strategic planning,

tactical training and intervention,

consultation with leadership, and the

development of a comprehensive crisis

plan.

PASTORAL

CRISIS INTERVENTION (PCI)

The functional integration of the

principles and practices of

psychological crisis intervention

with the principles and practices of

pastoral support. (Everly, IJEMH, 2000)

FOLLOW-UP & REFERRAL All forms of crisis intervention should

possess some form of follow-up.

In addition, one of the most cogent

reasons for instituting a crisis

intervention program is to identify

those who require or

desire continued care, and to

facilitate access to that care.

REMEMBER!

CISD / CISM are not substitutes

for psychotherapy.

Rather, they are elements within the emergency mental health system

designed to precede and complement psychotherapy, i.e., part of the full continuum of care.

Appendix B – Background Papers

Evolving Nature of Disaster Mental Health

Thoughts on Peer Support

Psychological Triage

Early Psychological Intervention: A Word of Caution

A Prospective Cohort Study of the Effectiveness of Employer – Sponsored Crisis Interventions after a Major Disaster

Economic Evaluation of CISM

assisting individuals in crisis

Documents